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U <br />DOMESTIC/MUNICIPAL PROGRAM <br />WELL ACCESS <br />dress: D Z -SLAA^"l o Date: Gf 15� (� <br />k <br />silent/Owner Name: <br />milling Date/Time: Li'l � ®% (Estimated sampling time is IS to 20 minutes) <br />`1aF{- o� cess Issues (Locks, Animals/Pets, Other): <br />Z=71 <br />�d <br />Iditional Well Info. (construction, pump depth) : Ql 04 ! o usG kv.A <br />sP;�at) <br />ell Use (last time used, purpose): t&z V Sf44 <br />Sampling is limited to analysis for volatile organic compounds. Resuks of the sampling program <br />will be used to assess the need for future semiannual sampling events at your well. <br />Print: <br />rks : <br />Acknowledgment: <br />1 agree to participate in the Forward Landfill Domestic Well Sampling Program and <br />authorize sampling of my well at no cost to me. I understand that I will be provided with <br />a report with the sample results when they are available. Additional sampling may occur <br />semiannually, and <br />Certification: <br />I must to be present during the sampling event, or <br />I do not need to be present during the sampling event. <br />I do no; agree to participate In the Forward Landfill Domestic Well Sampling Program. <br />